Healthcare Provider Details

I. General information

NPI: 1881788768
Provider Name (Legal Business Name): MARC A KUDELKO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13777 BELCHER RD S
LARGO FL
33771-4003
US

IV. Provider business mailing address

13777 BELCHER RD S
LARGO FL
33771-4003
US

V. Phone/Fax

Practice location:
  • Phone: 727-544-1600
  • Fax: 727-545-2555
Mailing address:
  • Phone: 727-544-1600
  • Fax: 727-545-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS7721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: